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Back  RFI # 583: Reporting Inactive

Formal vs. Informal Help Informal Formal

Submitter

Chris Baker

Description

At least one information source has stated, "There is no perfect code (AAA03) to say the member is active but not for the period requested;" therefore, the information source is responding with AAA03=52 (Service Dates Not Within Provider Plan Enrollment).

We believe the appropriate way to repond to an eligibility inquiry for a date of service for which the patient does not have active coverage is to return the date of service in 2100 DTP and 2110 EB01=6. Or if the information source desires to report the active period along with the inactive period, they could do so by sending 2 EB loops: one with EB01=6 and include 2110 DTP with the date of service, and one with EB01=1 with the eligibility date(s).

What would be most appropriate to report inactive coverage? 2100 AAA03=52? Or EB01=6 with date of service at either 2100 or 2110 level?

Submitter Assigned Keywords

Inactive AAA

Response

This issue is explicitly answered in guide 004010X092 in Section 1.3.7 which states for the 271 “An information source must respond with either an acknowledgment that the individual has active or inactive coverage or that the individual was not found in their system. The response will be for the date the transaction is processed, unless a specific date (prior, current or future) was used from the DTP of the EQ loop”.

Given that it is clear that the individual was found in the payer’s system, a status of Inactive (the appropriate code 6, 7 or 8 in EB01 and, 30 - Health Benefit Plan Coverage in EB03) must be returned. If no date was submitted in the 270 a date does not need to be returned in the 271 (implying inactive for the date the transaction was processed). If a date or range of dates were supplied in the 270 and was used to determine the eligibility status, the date(s) must also be returned in the 271 response, thereby indicating the inactive status of the individual for those dates.

Recommendation

AAA03=52 (Service Dates Not Within Provider Plan Enrollment) is not appropriate for the scenario described.
Submission 7/27/2007
Status Date 10/22/2007
Status F - Final
Primary References
Document 004010X092A1
Section1.3.7
Page20
Set ID004010